Sleep Intake Questionnaire
Thank you in advance for answering the following questions as best you can. This will help us learn more about you, so we can make the most of our time together.
Email
*
example@example.com
Name
*
First Name
Last Name
Referral Source
*
Occupation
*
Date of Birth
*
-
Month
-
Day
Year
Date
NATURE OF PRESENTING PROBLEM
Rate the current severity of your sleep concerns
Rows
None
Mild
Moderate
Severe
Difficulty falling asleep
Difficulty staying asleep
Difficulty waking up too early
How long have you had sleep concerns?
*
Identifiable precipitating factor(s)
*
Treatment history for current episode:
*
DAYTIME EFFECTS
To what extent do you consider your sleep difficulties to INTERFERE with your daily functions (e.g., daytime fatigue, ability to function at work/daily chores, concentration etc.)
Rows
1
2
3
4
5
Not at all (1) - Very much (5)
To what extent do you believe the following factors are contributing to your sleep difficulty?
Rows
None
Some
Much
Not applicable
Racing thoughts
Muscular pain or tension
Poor sleep habits
Daytime stress
Shift work
On average, how many nights each week do you have trouble falling asleep?
*
On average, how many nights each week do you have trouble staying asleep?
*
What wakes you up at night? (check all that apply)
*
pain
spouse
child
worries
hunger
temperature
noise
dreams
need to go to the bathroom
light
Other
If other, please specify
What is your usual bedtime on weekdays?
*
Hour Minutes
AM
PM
AM/PM Option
What time do you wake up in the morning?
*
Hour Minutes
AM
PM
AM/PM Option
Do you use an alarm to wake up?
Yes
No
If yes, how often do you hit the snooze button?
Do you have the same sleep-wake schedule on weekends?
Yes
No
Sometimes
Do you take naps?
Yes
No
Occasionaly
If yes, how many per week?
Are you currently taking prescription medication for sleep?
Yes
No
If yes, what medications are you taking currently??
How many caffeinated beverages do you drink per day?
None
1
2
3
4 or more
Other
If other, please specify
If yes, what caffeinated beverages do you drink?
Do you smoke cigarettes?
Yes
No
Occasionally
How many times each week do you exercise, on average?
None
1-2
3-4
5-6
7 or more
If yes, what type of exercise do you typically do?
Are you sleeping with a bed partner?
*
Yes
No
Occasionally
Is your bedroom quiet?
*
Yes
No
Do you have a TV in your bedroom?
*
Yes
No
Do you have a computer in your room?
Yes
No
Sometimes
Is your bedroom temperature comfortable at night?
*
Yes
No
Sometimes
During the past month, have you or your spouse ever noticed one of the following (check all that apply)
*
Crawling or aching feeling in your legs
Snoring
Pauses in breathing at night
Dry mouth in morning
Nightmares
Sleepwalking
Other
If other, please specify
What are the current stressors in your life
*
Do you recall dreaming when you wake up?
Yes
No
Occasionally
Other
If other, please specify
Please list accidents or incidents that may have affected your sleep.
What was your sleep like as a child?
Were you afraid of the dark as a child?
Yes
No
Can't remember
Other
If other, please specify
Thank you for taking your time to answer the questions. If there's anything else you would like me to know before our session, please list it below.
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